Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Sunday, February 24, 2008

When It Comes to Prevention: First, Do No Harm

"An ounce of prevention is worth a pound of cure."

- Ancient proverb

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“About 95 percent of our plans are similar. We both set up a government plan that would allow people who otherwise don't have health insurance because of a preexisting condition, like my mother had, or at least what the insurance said was a preexisting condition, let them get health insurance. We both want to emphasize prevention, because we've got to do something about ever escalating costs and we don't want children, who I meet all the time, going to emergency rooms for treatable illnesses like asthma.”

- Sen. Barack Obama, Democratic Debates 31 Jan 2008

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"We're going to make sure that we reduce costs by emphasizing prevention."

- Sen Barack Obama, Democratic Debates, 21 Feb 2008

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What does this line really mean in the health care debate: “We both want to emphasize prevention, because we’ve got to do something about ever escalating costs…” Would “prevention” have prevented Sen Obama’s mother’s pre-existing condition? Of course not. So why do we hear this?

Simple: because it sounds reassuring. It'll all be handled. Really it will.

But do "prevention" programs really reduce costs to our health care system? Can people with cancer or heart disease or pneumonia or multiple sclerosis “prevent” their disease? Can people “prevent” getting older? Can all accidents be “prevented?” How about arthritis or diabetes? Can we prevent their onset? Can government force people to eat less or stop smoking? Would we want this? Or in the case of the much ballyhooed genetic testing – can people really “prevent” a genetic disease from developing? As a doctor, I’d love to prevent all disease that afflicts man, but I know this is impossible. I rarely see patients until they have a problem - people just don’t want to think they could become sick.

But new “prevention” initiatives are underway by healthcare insurers who “reward” (bribe?) their policy members with financial incentives to participate in weight reduction classes and to stop smoking. We are told this will keep costs down. But the overall benefit to reducing costs to our healthcare system has not been clearly demonstrated. On the contrary, a recent study in the obese evaluated the lifetime costs of this disorder and concluded that although annual health-care costs are highest for obese people earlier in life (until age 56 years), and are highest for smokers at older ages, the ultimate lifetime costs are highest for the healthy (nonsmoking, nonobese) people. Hence the authors argue that medical costs will not be saved by preventing obesity. Could it be that cost savings are actually for the insurers who identify those “at risk” as defined by their industry’s own actuarial tables rather than real data?

Even with heart disease, we are now questioning the low LDL hypothesis and the use of statins as a means of improving myocardial infarction outcomes through lowering LDL levels in the blood. Certainly, most clinical cardiologists and primary care physicians do perceive that there is a reduction in the number of large Q wave myocardial infarctions recently. But why? Is it the statins? Or is it the implementation of anti-smoking legislation? Perhaps it’s because people are thinner. Or are they? It certainly couldn’t be because people are fatter – or could it?

Huge monies are involved in promoting therapies and testing for prevention. Companies need to “get the word out” to sell their wonder drugs and scanners. Nowhere is this better illustrated than the marketing of Gardasil by Merck to “prevent” cervical cancer. While the drug is good for specific forms of preventing cancerous precursors caused by the human papilloma virus, it is not perfect, since it immunizes for only four strains of human papilloma virus (6, 11, 16, and 18). But in an attempt to achieve perfection, boys are being considered as potential recipients of the vaccine – all at significant cost to our healthcare system. How many other viruses should we be similarly immunizing against? What would the cost be to our society?

What is clear is that programs and tests to perform “prevention” are consuming huge health care dollars – from advertising, marketing, frequent doctor visits, early CT scans, carotid ultrasounds, lipid monitoring, mammography, colonoscopy, genetic testing – all of these are expensive (and becoming more so). Just diagnosing something earlier – does that save healthcare costs or increase them overall? Early diagnosis might prevent later complications of disease, to be sure. But it might also increase the contact with the healthcare system and extend expensive treatments. Early diagnosis also provides a convenient means for insurers to deny a patient coverage if they change jobs. This might save the insurers costs, but the patient? Will this activity ultimately save overall healthcare costs or increase them? Also, additional earlier diagnosis might prolong the time until a definitive surgical cure takes place – adding additional follow-up costs. Finally, in the case of the dying, isn’t death remarkably economical to our healthcare system?

So before claiming that “prevention” programs will be our way of controlling healthcare costs, we should stop and ask if these programs save money or waste it. To do otherwise will doom our healthcare system to continued escalating costs in the name of "prevention."

Remember, when it comes or promising "prevention" programs as a means to save healthcare costs: Primum non nocere. (First, do no harm).

6 comments:

It seems by your tone that your mind is already made up. By grouping all "preventative" measures into one lump sum you are sort sighting the issue to the same extent as the presidential candidates. We certainly don't have the data right now on whether preventative medicine would be beneficial or harmful. Clearly there are types of prevention that are both cheap and effective. Nothing can prevent death, but certain things certainly can. Early detection in certain types of cancer enjoys widespread evidence for preventing death. Physical fitness is one of them as well, as those who are fit are half as likely to die than those who are unfit across a wide range of risk factors (see Meyers et al New England J. Medicine, 2002). I agree that delaying death may very well increase costs (as the recent study showing that lean people cost more in health care dollars than obese because they live longer), but the point of health care is to increase life regardless of finances. It is the oath that you took. However, until there is firm evidence against the notion of preventition should it not be encouraged regardless of the costs in certain situations. This is not a cut and dry issue and should not be treated as such, especially by an MD.

I agree with you that there are clearly some preventative measure that work and save costs, but there are many, many others that do not. To suggest that "prevention" will save overall healthcare costs to our system (as a mechanism to drive down Medicare costs, for instance) has never been demonstrated. My argument is I think, collectively, such measures are likely to increase costs.

As Cohen, et al, state in the referenced article:

"Some preventive measures save money, while others do not, although they may still be worthwhile because they confer substantial health benefits relative to their cost. In contrast, some preventive measures are expensive given the health benefits they confer. In general, whether a particular preventive measure represents good value or poor value depends on factors such as the population targeted, with measures targeting higher-risk populations typically being the most efficient. In the case of screening, efficiency also depends on frequency (more frequent screening confers greater benefits but is less efficient). Third, as is the case for preventive measures, treatments can be relatively efficient or inefficient."

I am not suggesting that prevention is not a laudible goal, but its one we must be realistic about when measures are applied to a large population base.

Exercise is a good illustration of the problem. Active people are healthier and live longer. This is partly because people who are ill are unable to exercise vigorously, but there are undoubtedly real benefits to increased exercise. Does it necessarily follow that medical interventions designed to increase activity are cost-efffective? It does not --even intensive programs cause a short term increase in activity but then people revert to their previous levels of physical activity. Before we give everyone free lifetime gym memberships paid for out fo healht insurance dollars, let's make sure it's cost effective and not just another perk for those who are already healthy and wealthy.

I think there is a real difference here between screening (for diseases which are easily treatable if identified at an early stage) and prevention, which attempts to reduce the incidence of a disease by targeted interventions.

The one case of direct behavioural action leading to a disease (smoking) has been used to make a case for all kinds of behavioural modification which in most cases have no clinical basis in the the data. These interventions are then "sold" as reducing costs in order to convince us that there is a societal benefit, as opposed to a reduction in personal freedom.

By pointing out that health - like everything else - is a question of costs and benefits and that resources put into one area represent a lost opportunity somewhere else, this article should make us think much more about accepting health interventions prior to any sign of disease.

Any mention of cost-benefit analysis in respect to health care gets howls protest in countries such as the UK and Canada (publicly-funded universal health care) with he complaints that you can't put a price on life. But you can and, in fact, must do this in order to resolve questions of resource allocation. One advantage of private health insurance is that these questions are (or should be) asked of new interventions, be they screening or prevention measures. That they are apparently not, according to this this article, suggests that there is cause for concern on a far greater level about the sustainability of the health care system

@Matt Layee: "Nothing can prevent death, but certain things certainly can. "Certain things can prevent death? I'd certainly love to hear of those; I am sure most people would want to live forever too. Or are you talking about postponing death? But then in some point in future one would still get sick and die. Or are you aware of some interventions that would guarantee that you'd just die instantly without ever needing end-of-life care? That is other than jumping off Empire State Building...

Except for you often need to screen 500-1000 of people for 10 years to prevent one death. During the same time about half of these people will have at least one chance of a false positive - e.g. with mammograms, all of which will require additional testing, some will require biopsy. And then there is this issue of overdiagnosis which means more screened people end up being treated for cancer. Are you even aware of how much some forms of screening - e.g. PSA, mammograms, increases incidence of the desease and that your risk of being diagnosed with the desease in your lifetime is actually less if you aren't screened even if your risk of dying from it maybe lower (in some cases)? And don't forget that some very agressive cancers will still kill, but screening advances time of diagnosis and thus increases time one is treated for a desease. Does it save some life-years -- absolutely for some percentage of some cancers. Does it save money - no way.

Lives saved don't equate savings, and savings is the topic of this discussion.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.